Metoclopramide and domperidone stimulate gastric emptying, small intestinal transit and enhance strength of oesophageal sphincter contraction. Avoid metoclopramide in children and those under 20 years of age because of the risk of dystonic reactions.

Esomeprazole should only be initiated by a consultant gastroenterologist in patients with treatment resistant severe GORD confirmed by endoscopy, who have failed to respond to the use of high doses of generic omeprazole and/or generic lansoprazole.

Esomeprazole should not be initiated by prescribers within primary care, nor should it be used in the treatment of dyspepsia or in H.pylori eradication regimes or for any other indication.

After 8 weeks therapy with esomeprazole patients should be reviewed and stepped down to a generic PPI where possible.

First line treatment in acute diarrhoea and gastro-enteritis is prevention or treatment of fluid and electrolyte depletion. For details of oral rehydration preparations see section9.2.1.2. In babies and infants it is unusual for this fluid to be required for more than about two feeds.

1.4.2 Antimotility drugs

These drugs for chronic bowel disorders are recommended for initiation only on specialist advice.

1.5.1 Aminosalicylates

Mesalazine

Mesalazine is an aminosalicylate that is used routinely to induce and maintain remission in chronic inflammatory bowel disease – ulcerative colitis (UC) and Crohn’s disease. Mesalazine is commonly given as a modified release (MR) preparation to target delivery of the drug to the diseased area of the bowel to provide topical anti-inflammatory therapy.

Available formulations have differences in licensed indications, tablet strengths, pharmaceutical, pharmacological and pharmacokinetic properties. As the delivery characteristics of the different mesalazine preparations may vary: mesalazine preparations must be prescribed by brand name.

Octasa® is the first line choice across the ELMMB healthcare economy, and where possible 800mg strength tablets should be prescribed and supplied. Patients currently taking generic mesalazine or Asacol® can be switched to Octasa®. Switching to Octasa® in patients currently taking other brands of mesalazine can be considered, but response needs to be monitored as brands are not directly interchangeable.

who have not responded to conventional treatment. Linaclotide can be considered as an option (specialist initiation

only) for the treatment of persistent constipation in adults with IBS who have not responded to conventional treatment

based on suggested treatment pathway:

1. Follow irritable bowel syndrome in adultsNICE CG61 (2008) and manage constipation with a range of

osmotic and stimulant laxatives with the long-term use of soluble fibre

2. Where antispasmodics and laxatives are ineffective for pain relief, NICE suggests the use of tricyclic

antidepressants (unlicensed use)

3. Assess patient at 4 weeks (in secondary care) and if no improvement discontinue use

4. If continued beyond 4 weeks, re-assess at 6 months for contniued benefit

AMBER Linaclotide capsules 290 micrograms

Lubiprostone (Amitiza®) is recommended as an option for treating chronic idiopathic constipation, that is, for adults in whom treatment with at least 2 laxatives from different classes, at the highest tolerated recommended doses for at least 6 months, has failed to provide adequate relief and for whom invasive treatment for constipation is being considered.

If treatment with lubiprostone is not effective after 2 weeks, the person should be re-examined and the benefit of continuing treatment reconsidered. Treatment should only be prescribed by a clinician with experience of treating chronic idiopathic constipation. As per NICE TAG 318 guidance.

AMBER Lubiprostone (Amitiza®) capsules 24mcg

Naloxegol (Moventig®) is recommended, within its marketing authorisation, as an option for treating opioid induced

constipation in adults whose constipation has not adequately responded to laxatives

> An inadequate response is defined as opioid‑induced constipation symptoms of at least moderate severity in

1.9.1 Drugs affecting biliary composition and flow

Mainly used for unlicensed use in itching related to gall bladder problems

AMBERUrsodeoxycholic acid

tablets 150mg,capsules 250mg

suspension 250mg in 5mLRED Obeticholic acid▼ NHS England Commissioned film coated tablets 5mg, 10mgPatients should be reviewed 12 months after initiation to review effectiveness and treatment should only continue if there is evidence of clinical benefit - as per NICE TA443